Provider Demographics
NPI:1871095711
Name:ISLAND MEDICAL BLUEFIELD LLC
Entity type:Organization
Organization Name:ISLAND MEDICAL BLUEFIELD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-656-5911
Mailing Address - Street 1:PO BOX 74622
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0002
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:
Practice Address - Street 1:500 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-327-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISLAND MEDICAL BLUEFIELD LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-07
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty